Parent-Child Interactions in Behavioral Treatment of Selective Mutism: A Case Study
Christina M. Mele
Department of Applied Psychology, New York University
Individuals with Selective Mutism are often talkative at home, but experience a persistent
failure to speak in other social environments, such as school.


Symptoms become evident when children attend school, where there are expectations to
engage verbally with teachers and peers.
In order to address these impairments, the goal of treatment is for children to speak with
various people and in multiple settings (i.e., generalization).
Behavioral treatment is considered an effective intervention for children with Selective
Mutism.
Child’s and
adult’s
anxiety are
lowered
Child gets
anxious


The case study examined mother-child interactions to determine the ways in which a parent
verbally engaged with her child in the treatment of Selective Mutism.
Three main questions guided the study:
1. What is the child’s verbal response rate to questions (i.e., yes/no, forced-choice, and openended) by mother and questions by therapist (i.e., trained adult staff)?
2. How does the child’s response rate to therapist’s direct and indirect commands to verbalize
change over the course of treatment?
3. How does the contingent response rate to the child’s speech provided by the mother and
therapist change over time? In addition, how do the child’s response rate to valid questions
(i.e., forced-choice and open-ended), response rate to therapist’s commands to verbalize,
and rate of spontaneous speech (i.e., unprompted verbalizations) change during the course
of treatment?
Child demonstrated a higher response rate to the
parent’s questions when provided with opportunity to
respond (i.e., at least five seconds) than to all
questions combined.
Child’s response rate to yes/no questions was stable;
response rate to forced-choice and open-ended
questions (with opportunity) decreased across the 3
parent-present sessions.
Child’s response rate to questions with opportunity
decreased from Session 2 to 3, which might relate to
the therapist’s decision to fade mother out of the
sessions (i.e., become less verbally active and less
physically involved in session, while fading therapist in
more at the same time).
30
20

Labeled Praise:
Specifically attends to
child’s speech.
E.g., “Great telling me
that you want the
ball!”

Reflection:
Repeats child’s
verbalization.
E.g., “You said ‘ball.’”

Unlabeled Praise:
Does not specifically
address child’s speech.
E.g., “Great job!”
Acknowledgement:
Answers child’s
question or
acknowledges the
child’s statement.
E.g., “Sure, the ball.”

80
Session #1
100
Session #2
Session #3
Session #4
Session #5
2
3
4
5
6
Session #2
Session #1
Indirect
Parent and therapist provided
high rates of contingent
responses (i.e., labeled praises,
reflections, unlabeled praises,
and acknowledgements) to child’s
verbalizations, i.e., > 90%.
Child’s response rate to all valid
adult prompts to verbalize, and
rate of child spontaneous speech,
increased as a function of time
and treatment.
There was a decrease in the
child’s response rate to valid
prompts to verbalize and child’s
rate of spontaneous speech in
Session 3, perhaps due to parent
fade-out procedure.
Contingent Responses to Child Speech
Absence of Parent
Presence of Parent
100
2.0
80
60
1.0
40
20
0
0.0
1
2
3
4
5
6
Session
Child's Response Rate to Commands and Valid Questions
Contingent Responses to Child's Speech
Spontaneous Speech (SS)
DISCUSSION

Results show that the child’s response rate to valid prompts to speak by parent and
therapist increased during treatment.

Child Response to Parent Questions
Session #3
60
Results show that child’s response rate to therapist’s direct and indirect commands to
verbalize increased during the phase when parent was absent.

Parent and therapist provided a high rate of contingent responses to the child’s
verbalizations over the course of six sessions.

Child’s rate of all spontaneous verbalizations increased four-fold as a function of time and
treatment.

The decrease in the child’s verbalizations in Session 3 might reflect an increase in anxious
avoidance when parent was faded out of the room per standard treatment protocol.

Continued research is needed to enhance our understanding of the ways in which parents
and therapists can promote, or hinder, the speaking of children with Selective Mutism.
50
40
30
20
Additional factors, including the presence of multiple therapists, frequency of question
type, and frequency of command type, might also influence the observed trends in
child’s response rate.

70
10
0
Yes/No
FCQ/OEQ
Yes/No
FCQ/OEQ
Yes/No
FCQ/OEQ
Question Type
Child Response to Therapist Questions
Percent Response to Questions


PURPOSE OF THE STUDY
40
Direct
RQ1: CHILD’S RESPONSE RATE TO QUESTIONS
Child avoids
Involving parents in treatment may afford them with the necessary skills to foster a
positive way of interacting with their children.
50
RQ3: CONTINGENT RESPONSE RATE TO CHILD’S SPEECH
Contingent
Responses to
Child’s Speech
Open-Ended:
A query that allows
for verbal
elaboration.
E.g., “What toy do
you want next?”



Session
Forced Choice:
A query with two
or more choices.
E.g., “Do you want
the ball or another
toy?”
Child is
prompted to
talk or
engage
Adult
rescues
60
Child demonstrated a higher response
rate to the therapist’s direct
commands to verbalize than to indirect
commands in the first phase of
treatment, but not in the second
phase.
The decrease in the child’s response
rate to therapist’s commands to
verbalize in Session 3 might reflect an
increase in anxious avoidance as the
therapist instructed parent to fade out
of the room.
There was a steady increase in child’s
response rate to all therapist’s
commands to verbalize in the second
phase of treatment, notably reaching
100% by the sixth session.
Rate per Minute of SS
Model behavior that reinforces their children’s avoidance of verbal communication.
70
1
Yes/No:
A query answered
with yes or no.
E.g., “Do you want
the ball?”
Indirect:
A suggestion to
verbalize.
E.g., “You can tell me
what you want to
play with next.”
Engage in less positive verbal reinforcement with their children.

80
0
Questions
Direct:
An imperative to
verbalize.
E.g., “Tell me what
you want to play
with next.”
Observations of parent-child interactions show that parents of children with anxiety disorders:
Ask their children frequent questions without opportunities to verbally respond.

Absence of Parent
90
All parent-child and therapist-child verbal interactions were transcribed and later coded using an
adaptation of the Selective Mutism Behavioral Observation Coding System (Kurtz, in preparation) and
Dyadic Parent-Child Interaction Coding System (Eyberg et al., 2005).
Research has suggested that parents’ interaction styles play a role in the maintenance of anxiety
symptoms.

100
TRANSCRIPTION & CODING
PARENTAL INVOLVEMENT IN TREATMENT


Six therapeutic sessions were video-recorded.
Interactions involved developmentally
appropriate, game-based play activities for
children and adults together (e.g., cards, doll
play).
Therapists were faded into sessions in the
presence, then in the absence, of the parent
with the child.
Presence of Parent
10
Commands


Child met full diagnostic criteria for Selective
Mutism only.




Mother and five-year-old daughter attended six
therapeutic sessions over a five-week period in
a clinical office.


Child Response to Therapist Commands to Verbalize
Data for this case study were from ongoing
treatment of a child with Selective Mutism at
the Child Mind Institute.

PROCEDURE
Percent Response

Selective Mutism (SM) is a childhood anxiety disorder that affects children’s social functioning
in a variety of settings.
PARTICIPANTS & SETTING
Percent Response to Questions

RQ2: CHILD’S RESPONSE RATE TO THERAPIST COMMANDS
METHOD
Percent Response to Commands
DIAGNOSIS & TREATMENT OF SELECTIVE MUTISM
Response Rate with Opportunity
Session #6
Response Rate to All Questions
80

60
40
20

0
Y/N
FCQ/OEQ
Y/N
FCQ/OEQ
Y/N
FCQ/OEQ
Y/N
FCQ/OEQ
Y/N
FCQ/OEQ
Y/N
FCQ/OEQ
Question Type
Response Rate with Opportunity
Response Rate to All Questions
There was a steady increase in the child’s response
rate to therapist’s forced-choice and open-ended
valid questions (i.e., provided child with opportunity
to respond verbally).
The therapist did not ask the child yes/no questions
in the first two sessions. Child demonstrated a steady
increase in response rate to the therapist’s valid
yes/no questions from Session 3 to 5.
ACKNOWLEDGEMENTS
I would like to extend my gratitude to Dr. Steven Kurtz for his expertise, guidance, and tremendous
encouragement throughout the duration of this project and my fieldwork experience at the Child Mind
Institute. I would also like to thank Dr. Melissa Ortega for her supervision and support during this treatment
intervention, Wendy Ramirez for her dedication, and the Selective Mutism Program.
I would like to thank Dr. Gigliana Melzi for her guidance and support throughout this process. I would also like
to thank Adina Schick and Kristin Lees for their help and encouragement.
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Parent-Child Interactions in Behavioral Treatment